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What’s in the Senate health care bill and what happens next

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here.

Senate Republicans have finally released a health care bill. It keeps much of Obamacare's private insurance market, though it ratchets down the financial assistance. It cuts taxes. And it cuts Medicaid, by rolling back the Obamacare expansion and putting a spending cap on the program.

It's a lot to digest. Read Sarah's full explainer here. But this is the big takeaway:

"The bill asks low- and middle-income Americans to spend significantly more for less coverage."

Or as Ezra Klein summed it up: "Policy after policy in the bill is built to achieve the same goal: making poor people pay more for less health insurance."

Dylan Matthews has a rundown of the people the plan would hurt. Julia Belluz reviewed the different ways the bill could roll back women's health care in particular.

This looks like a bill that Senate Majority Leader Mitch McConnell wrote — after entirely secret negotiations — to give both his conservative and his moderate senators some wins and some losses. He needs 50 of the 52 Senate Republicans to vote for the bill to pass it.

If senators decide that the most important thing to them is saying they repealed Obamacare, there is a path to yes for all of them, as I wrote here.

That's a real dynamic. Here's how one Republican explained it to Sarah today:

"It's going to be really hard to explain to your Republican constituents who elected you that you couldn't support the thing you've been campaigning on."

Four Republican senators — Rand Paul, Ted Cruz, Mike Lee, and Ron Johnson — have already said they'd oppose the bill as written, as Andrew Prokop reported. But they've signaled a willingness to come around.

"We are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor," the senators said.

Paul told reporters that the current bill kept too much of Obamacare, by maintaining its subsidy structure and keeping many of its regulations. Maybe McConnell has a proposal up his sleeve that could help bring them around.

For moderate senators, who are worried about the Medicaid cuts, there is another possible area for compromise: funding for the opioid crisis. The current bill provides $2 billion for opioid programs in 2018. As Ella Nilsen wrote, that's not nearly enough.

Sens. Rob Portman (R-OH) and Shelley Moore Capito (R-WV) had been asking for $45 billion over 10 years. It seems possible that the $2 billion currently in the bill could be increased to help appease their concerns about the Medicaid cuts.

Thursday's release was step one. A lot of senators still have concerns about the bill, and negotiations are still open.

"There are some things we've said all along that are dialable, that we can hopefully tweak a little bit before it comes to the floor," Sen. John Thune (R-SD) told reporters Thursday.

A Congressional Budget Office analysis will come early next week. McConnell is aiming for a vote by the end of the week. It's all happening fast, but we still have a long way to go.

Chart of the Day

Medicaid cuts and tax cuts. That's what so much of the Republican health care plan is about, as this chart puts in stark terms. Read more from CBPP here.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today's top news

  • "Four GOP senators oppose Senate health-care measure in its current form": “Four Republican senators from the conservative wing of their party say they oppose the Senate health-care bill as it was introduced by Senate Majority Leader Mitch McConnell on Thursday, which places the effort to overhaul the American health-care system in jeopardy as it heads for an anticipated vote in the Senate next week. Those senators — Rand Paul of Kentucky, Ted Cruz of Texas, Ron Johnson of Wisconsin and Mike Lee of Utah — announced that while they cannot support the bill as its currently written, they are open to negotiating changes that could ultimately win their support.” —Sean Sullivan, Juliet Eilperin and Kelsey Snell, Washington Post
  • "Cruz can't support health bill, but wants to make a deal": “Sen. Ted Cruz says he hasn't given up on the Senate health care bill. He already released a statement with three other Republicans saying they're 'not ready to vote for' the draft bill. But in a separate statement, Cruz says he wants to help make 'real improvements' so it 'provides the relief from Obamacare that Republicans have repeatedly promised the last seven years' — especially in reducing health insurance premiums.” —David Nather and Jonathan Swan, Axios
  • "Obama slams 'fundamental meanness at the core' of Senate healthcare bill": “Former President Barack Obama on Thursday blasted Senate Republican leaders' plan to overhaul large parts of his signature healthcare legislation, ObamaCare. 'The Senate bill, unveiled today, is not a health care bill,' he wrote in a Facebook post. 'It’s a massive transfer of wealth from middle-class and poor families to the richest people in America.'” —Max Greenwood, the Hill
  • "Senate Democrats launch tactics to slow work on health care bill": “Senate Democrats on Thursday launched their strategy to fight the GOP's health care bill by trying to prevent it from getting a quick vote. Senate Minority Leader Chuck Schumer of New York and other Democratic leaders began a series of procedural requests to slow down consideration of the legislation, a discussion draft of which posted shortly before the Senate convened.” —Nicole Guadiano, USA Today

Analysis and longer reads

  • "Republicans' Health-Care Bills Boil Down to ... More Obamacare": “I called the House health care bill 'Obamacare Lite,' but compared to the Senate bill, the House was offering a radical new taste sensation. The Senate bill touches very little of the underlying architecture of Obamacare; all it does is eliminate the insurance mandates, cut spending and give states somewhat more autonomy in how those dollars are spent.” —Megan McArdle, Bloomberg
  • "Republicans' Proposed Medicaid Cuts Would Hit Rural Patients Hard": “For the hundreds of rural U.S. hospitals struggling to stay in business, health policy decisions made in Washington, D.C., this summer could make survival a lot tougher. Since 2010, at least 79 rural hospitals have closed across the country, and nearly 700 more are at risk of closing. These hospitals serve a largely older, poorer and sicker population than most hospitals, making them particularly vulnerable to changes made to Medicaid funding.” —Bram Sable-Smith, NPR
  • "Senate GOP’s Health Care Process Goes Unnoticed, Polling Shows": “Left-leaning activists, health analysts and other opponents have spent much of the month bemoaning a lack of media coverage on Senate Republicans’ secretive efforts to draft their legislation to repeal and replace significant parts of Obamacare. Morning Consult polling from recent weeks shows they may have an argument, with a variety of news stories — many pertaining to President Donald Trump — resonating more with the American public.” —Cameron Easley, Morning Consult

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